01/14/2013 ConfidentialPage 110/04/2018
CONNECTICUT PROFESSIONALPROVIDER MANUAL
Contents
Introduction and Guide to Manual
Purpose and Introduction
Future Updates
Information Sources
Legal and Administrative Requirements Overview
Insurance Requirements
Dispute Resolution and Arbitration
Directory of Services
Network Participating Provider Service Centers
Secure E-Mail
Network Update and Rapid E-Mail Services
Quick Reference Guides
Who is Here for You?
The BlueCard® Program
Federal Employee Program
Provider Websites
Anthem.com
Anthem Online Provider Services (“AOPS”)
How to Enroll
AOPS Network Participating Provider Reference Material
AOPS Coverage and Benefit Inquires
AOPS Claims Status Inquiry
AOPS Training and Feedback
Availity Multi-Payer Portal
Eligibility
Identification Card
Claims Submission
Electronic Data Interchange (EDI)
Online EDI Resources & Contact Information
Contacting the EDI Solutions Helpdesk
Submitting & Receiving EDI Transactions
Troubleshooting Electronic Submissions
Make the Most of Your Electronic Submissions Coordination of Benefits (COB)
Medicare Crossover Claims
EDI Reports Speed Account Reconciliation
Paperless Payment Program for Network/Participating Providers - Electronic Remittance Advise (ERA)
Electronic Funds Transfer (EFT)
Real Time Electronic Transactions
National Provider Identifier (NPI)
National Uniform Billing Committee- CMS-1500
MD Online Web-Based Electronic Claim Submission Services
Paper Claim Submission
Mailing Addresses
Submission of Claims under the Federal Employee Health Benefit Program
Erroneous or duplicate Claim payments under the Federal Employee Health Benefit Program
Ancillary Claim Filing
Commercial Plans Overpayment Recovery Process
BlueCard® National Accounts Overpayment Recovery Process
Federal Employee Program (FEP) Overpayment Recovery Process
Claim Filing Tips
Timely Filing Limits
Timely Filing for Adjustments & Corrected Claims
Balance Billing
Preventable Adverse Events
Reimbursement and Billing Policies
Medical Policies and Clinical Guidelines
Finding Medical Polices and Clinical UM Guidelines
Contact Us – Medical Policy
Utilization Management
Services Requiring UM
Telephonic Pre-service Review & Concurrent Review
Medical Policies and Clinical UM Guidelines Link
Prior Authorization and Inpatient Services
On-Site Continued Stay Review
Observation Bed Policy
Retrospective Utilization Management
Failure to Comply with Utilization Management Program
Care Management
Care Management Referrals
Utilization Statistics Information
Reversals
Quality of Care Incident
Audits
Milliman Care Guidelines®
HMO Products
PPO Plans and Products with Managed Benefits
Prior Authorization of Services
Managed Benefits
Notification requirements for Covered Individuals with Managed Benefits
Balance Billing for Services Considered Not Medically Necessary
Maternity
Expedited Review Hotline-Inpatient Care
Emergency Admission Authorization
Urgent Care
Behavioral Health Treatment
Physician/Provider Participation Requirements
Participating Physician, Provider and Group Agreements
Participation Confirmation and Effective Dates
Defining Solo vs. Group Practices
Changing Your Practice
Notifying Covered Individuals of Participation Status
Open Practice
Adding New Providers to Group Practices
Participation through a Provider Sponsored Organization
When to Submit an Agreement
How to Complete an Agreement
Notification of Changes
Physician/Provider HMO Access Goals and Calendar Requirements
Calendar Access Requirements
24/7 Coverage Requirements for Par Providers
Hospitalist Programs
Locum Tenens
Provider Termination Without Cause
Continuation of Care
Credentialing
Credentialing Scope
Credentials Committee
Nondiscrimination Policy
Initial Credentialing
Recredentialing
Ongoing Sanction Monitoring
Appeals Process
Participating Provider Appeals of Sanctions Policy and Procedure
Reporting Requirements
Anthem Credentialing Program Standards
Quality Management Program
Anthem Quality Insights (AQI)Incentive Program for Professional Providers
Anthem Centers of Medical Excellence (“CME”) Transplant Network
Blue Distinction Centers of Excellence Programs
Blue Distinction Centers for Transplants
Laboratory Services
360° Health
What is 360° Health?
Improving Health with innovative Tools & Resources
Tools available to your patients
Guidance from Clinical Experts
Managing Conditions
Covered Individual Grievance and Appeal Process
Covered Individuals Bill of RIghts and Responsibilities
Provider Complaint and Appeals Process
MediBlue Appeals
Product Summary
Group Health
Medicare Advantage
Medicare Supplemental
Lumenos Consumer Driven Health Plans
Tonik
The BlueCard® Program
Federal Employee Program
FEP Program Requirements
Coordination of Benefits for FEP
Empire Blue Cross and Blue Shield HMO/POS
Plans
Eligibility and Claims Status Inquiries
Prior Authorization
New England Health Plans
Utilization Management
Benefit Programs
HMO Blue New England
Blue Choice New England Point of Service Program
Access Blue New England
Behavioral Health Care
Taft Hartley
Medicare Advantage
Preferred Provider Organization
MediBlueSM HMO
Audit
Enterprise Audit Policy
Audit Appeal Policy
Exhibits
How to Read a Nasco Remit
Anthem Online Provider Services Registration Form and User Agreement
Overpayment Recovery Request Form
Provider Maintenance Form
Medical Record Submission Form
Useful Links
Introduction and Guide to Manual
Purpose and Introduction
The Anthem Blue Cross and Blue Shield (Anthem) Professional Provider Manual has been revised to present an overview of the most current policies and procedures as a reference for participating professional providers. In keeping with the transition to an increasingly paperless environment, this provider manual contains many references to information that will be found, and maintained, on our website at More information on accessing our website can be found in this manual under the heading Information Sources.
Anthem Blue Cross and Blue Shield is committed to providing Network/Participating Providers with an accurate and current manual; however, there may be instances in which changes occur between manual revision dates. The information contained in this provider manual will be reviewed and updated on an annual basis.
Information Sources
Any changes to the information contained herein will be communicated via notice posted to direct mailings to providers, Rapid E-mail service, and/or Anthem’s bi-monthly Network Update until such time as the provider manual is next updated. In those instanceswhere Anthem determines that information in the manual differs from that of the Anthem Participating Provider Agreement (the “Agreement”,) the Agreement will take precedence over the manual.
The information contained in this provider manual will be reviewed and updated on an annual basis.
Information Sources
Anthem Web Site – An internet site that is available to providers at The site provides information on:
- Anthem products
- Contact phone numbers
- Provider services
- Health information
- Network/Participating Provider directories
ANTHEMNetwork Update - Our Network/Participating Provider newsletter, Network Update, is our primary source for providing important information to Network/Participating Providers. The Network Update is available six (6) times a year on and via email distribution. You can easily locate the bi-monthly online editionbyloggingontoCT>then scroll to Network/Participating Provider Newsletters on the provider home page. We encourage you to sign up for the email delivery of a link to the newsletter directly in your email inbox. Registration for this service is available at >Anthem Network Updates Rapid Email Service
Legal and Administrative Requirements Overview
Insurance Requirements
- Network/ Participating Providers and Facilities shall, during the term of this Agreement, keep in force with insurers having an A.M. Best rating of A minus or better, the following coverage:
- Professional liability/medical malpractice liability insurance with limits of not less than $1,000,000 per claim and $3,000,000 in the aggregate which shall pay for claims arising out of acts, errors or omissions in the rendering or failure to render the services to be obtained under this Agreement.If this insurance policy is written on a claims-made basis, and said policy terminates and is not replaced with a policy containing a prior acts endorsement, Providers and Facilitiesagrees to furnish and maintain an extended period reporting endorsement ("tail policy") for the term of not less than three (3) years in the amount not less than the per claim and aggregate values indicated above.Professional liability/medical malpractice limits may be satisfied with a combination of primary and excess coverage. Additionally, in states with patient compensation funds, a Network/Participating Provider or Facility may have less insurance coverage if the patient compensation fund, when considered with Network/Participating Provider’s or Facility’s insurance and any applicable limits on damage awards, provides equivalent coverage.
- Workers’ Compensation coverage with statutory limits and Employers Liability insurance
- Commercial general liability insurance for Facilities with limits of not less than $1,000,000 per occurrence and $2,000,000 in the aggregate for bodily injury and property damage, including personal injury and contractual liability coverage. (These commercial general liability limits are encouraged for Providers, as well);
B. Self-Insurance can be in the form of a captive or self-management of a large retention through a Trust. A self-insured Network/Participating Provider or Facility shall maintain and provide evidence of the following upon request:
- Actuarially validated reserve adequacy for incurred Claims, incurred but not reported Claims and future Claims based on past experience;
- Designated claim third party administrator or appropriately licensed and employed claims professional or attorney;
- Designated professional liability or medical malpractice defense firm(s);
- Excess insurance/re-insurance above self insured layer; self insured retention and insurance combined must meet minimum limit requirements; and
- Evidence of surety bond, reserve or line of credit as collateral for the self-insured limit.
C.Network/Participating Providers and Facilities shall notify Anthem of a reduction in, cancellation of, or lapse in coverage within ten (10) days of such a change.A certificate of insurance shall be provided to Anthem upon request.
Dispute Resolution and Arbitration
The substantive rights and obligations of Anthem,Providersand Facilities with respect to resolving disputes are set forth in the Anthem Facility Agreement (the "Agreement") or the Anthem Provider Agreement (the “Agreement”). The following provisions set forth some of the procedures and processes that must be followed during the exercise of the Dispute Resolution an Arbitration Provisions in the Agreement.
- Cost of Non-binding Mediation
The cost of the non-binding mediation itself will be shared equally between the parties, except that each party shall bear the cost of its attorney’s fees.
- Location of the Arbitration
The arbitration will be held in the city and state in which the Anthem office identified in the address block on the signature page to the Agreement is located except to the extent both parties agree in writing to hold the arbitration in some other location.
C.Selection and Replacement of Arbitrator(s)
For disputes requiring a three (3) arbitrator panel under the terms of Article VII of the Agreement, then the panel shall be selected in the following manner. The arbitration panel shall consist of one (1) arbitrator selected by Provider or Facility, one (1) arbitrator selected by Anthem, and one (1) independent arbitrator to be selected and agreed upon by the first two (2) arbitrators. In the event that any arbitrator withdraws from or is unable to continue with the arbitration for any reason, a replacement arbitrator shall be selected in the same manner in which the arbitrator who is being replaced was selected.
- Discovery
The parties recognize that litigation in state and federal courts is costly and burdensome. One of the parties’ goals in providing for disputes to be arbitrated instead of litigated is to reduce the costs and burdens associated with resolving disputes. Accordingly, the parties expressly agree that discovery shall be conducted with strict adherence to the rules and procedures established by the mediation or arbitration administrator identified in Article VII of the Agreement, except that the parties will be entitled to serve requests for production of documents and data, which shall be governed by Federal Rules of Civil Procedure 26 and 34.
E.Decision of Arbitrator(s) and Cost of Arbitration
The decision of the arbitrator, if a single arbitrator is used, or the majority decision of the arbitrators, if a panel is used, shall be binding. The arbitrator(s) may construe or interpret, but shall not vary or ignore, the provisions of this Agreement and shall be bound by and follow controlling law (except to the extent the Agreement lawfully requires otherwise, as in the case of the statute of limitations). The arbitrator(s) may consider and decide the merits of the dispute or any issue in the dispute on a motion for summary disposition. In ruling on a motion for summary disposition, the arbitrator(s) shall apply the standards applicable to motions for summary judgment under Federal Rule of Civil Procedure 56. The cost of any arbitration proceeding under this section shall be shared equally by the parties to such dispute unless otherwise ordered by the arbitrator(s); provided, however, that the arbitrator(s) may not require one party to pay all or part of the other party’s attorneys’ fees. Judgment upon the award rendered by the arbitrator(s) may be confirmed and enforced in any court of competent jurisdiction. Without limiting the foregoing, the parties hereby consent to the jurisdiction of the courts in the State(s) in which Anthem is located and of the United States District Courts sitting in the State(s) in which Anthem is located for confirmation and injunctive, specific enforcement, or other relief in furtherance of the arbitration proceedings or to enforce judgment of the award in such arbitration proceeding.
- Confidentiality
All statements made, materials generated or exchanged, and conduct occurringduring the arbitration process, including but not limited to materials produced during discovery, arbitration statements filed with the arbitrator(s), and the decision of the arbitrator(s), are confidential and shall not be disclosed in any manner to any person who is not a director, officer, or employee of a party or an arbitrator or used for any purpose outside the arbitration.
Directory of Services
A listing of phone numbers for our Provider Call Centers, Electronic Data Interchange (EDI) and Anthem Online Provider Services (AOPS) Help Desks, Utilization Management (“UM”) and Other Provider Call Centers may be found below. For the most comprehensive and current listings, please refer to Providers> CT> Contact Us. Please note that the listing below for Provider Service Centers includes the Covered Individual identification prefixes associated with each product in the event that you require a cross-reference to determine the appropriate Provider Service Center for your inquiries. The website also includes contact information for the Institutional and Professional Network Relations Consultants who are assigned by geographic location or facility.
Network/Participating Provider Service Centers
Provider Service Centers / Hours of Operation / Telephone Numbers / Covered IndividualIdentification (“ID”) Number Prefixes Handled by ServiceCenterNetwork/Participating ProviderCallCenter
(local Anthem plans) / XG*, CKC, OTW, PHT, PRG, URR
*third alpha character will vary
Professional / 8:00 a.m. - 5:00 p.m.
Monday – Friday
(IVR available 24/7) / (800) 922-3242
Institutional / 8:00 a.m. - 5:00 p.m.
Monday – Friday
(IVR available 24/7) / (800) 345-2227
Medical Management / 8:00 a.m. – 5:00 p.m. Monday - Friday / (800) 238-2227
New England Health Plan (“NEHP”) and **Empire HMO plans / CTN, CTP, EHF, EHG, EHH, EHJ, MEN, MEP, MTN, MTP, NHN, NHP
**Empire prefixes - YLF, YLL, YLQ, POS, POP
Eligibility and Benefits / 8:00 a.m. – 5:00 p.m. Monday – Friday / (800) 676- BLUE (2583
Claim inquiries / 8:00 a.m. - 5:00 p.m.
Monday – Friday
(IVR available 24/7) / (800) 238-2465
Medical Management / 8:00 a.m. – 5:00 p.m. Monday – Friday / (800) 238-2227
Tri-state
Anthem plans in Connecticut, Maine and New Hampshire utilize the same membership and Claims systems; therefore, inquiries for Covered Individuals in Maine and New Hampshire are considered local or ‘tri-state’ inquiries. Please contact the following numbers for the specified prefixes.
Anthem Maine
(tri-state) / 8:00 a.m. - 5:00 p.m., Monday – Friday
(IVR available 24/7) / (800) 832-6011 / XVA, XVB, XVG, XVH, XVP
AnthemNew Hampshire (tri-state) / 8:00 a.m. - 5:00 p.m., Monday – Friday
(IVR available 24/7) / (800) 332-6558 / YGA, YGC, YGF, YGG, YGK, YGM
BlueCard® ServiceCenter
Eligibility and benefits / 8:00 a.m. - 5:00 p.m.
Monday - Friday / (800) 676-BLUE (2583) / All prefixes not listed elsewhere in this grid
Claim Inquiries / 8:30 a.m. - 5:00 p.m.
Monday – Friday
(IVR available 24/7) / (800) 895-9915
Precertification / (800) 676-BLUE (2583) Option 4
Taft-Hartley / Teamsters / 8:00 a.m. - 5:00 p.m.
Monday - Friday / (888) 287-0032 / CCU, CWV, ELH, EWU, IRU, IUB, IUP, NEF, NEH, NIW, PSH, PTH, SVL, TLH, TSJ
Precertification / See Covered Individual’s ID card
Federal Employee Program® (“FEP”) / Monday - Wednesday, Friday:
8:00 a.m. - 5:30 p.m.
Thursday: 9:00 a.m. - 5:30 p.m.
(IVR available 24/7) / (800) 438-5356 / R (followed by 8 digits)
MediBlueSM HMO and PPO
Eligibility, Benefits and Claims / 8:00 a.m. - 8:00 p.m.
Monday - Friday / (866) 673-4157 / XGH(HMO), XGK (PPO)
Precertification / (877) 657-6115
Medicare Advantage other HMO and PPO plans throughout the United States / variesby state / see Covered Individual’s ID card / Varies by state
Technical Support
Anthem Online Provider Services (“AOPS”)
-Online Provider Services password changes or requests
Availity / (866) 755-2680
(800)282-4548
Electronic Data Interchange (“EDI”)
-Enrollment and testing for EDI services
-Transmissionor connection support for EDI services / (800) 334-8262
Other Provider Call Centers:
Other Provider Call Centers / Telephone Numbers
Anthem Behavioral Health / 1-800-934-0331
Anthem Dental / 1-800-548-0642
AIM Specialty Health / 1-866-714-1107
Anthem Vision / 1-888-799-6290
OrthoNet (PT, OT Authorizations) / 1-888-788-0807
SecureE-Mail
Secure E-mail is a service that allows providers to communicate directly with Utilization Management (“UM”) and several of our Provider Call Centers directly via e-mail for quick, convenient, and documented responses to your inquiries. You will find references to electronic medical records submission, electronic prior authorization reviews, and Provider Call Center e-mail mailboxes throughout our website; each of which will require that you are registered for secure e-mail service in order to protect the health information of Covered Individuals that is being transmitted.